N.Y. Public Health Law § 2111: Disease management demonstration programs

§ 2111. Disease management demonstration programs. 1. The department

may establish disease management demonstration programs through a

request for proposals process to enhance the quality and

cost-effectiveness of care rendered to medicaid-eligible persons with

chronic health problems whose care and treatment, because of one or more

hospitalizations, multiple disabling conditions requiring residential

treatment or other health care requirements, results in high medicaid

expenditures. In order to be eligible to sponsor and to undertake a

disease management demonstration program, the proposed sponsor may be a

not-for-profit, for-profit or local government organization that has

demonstrated expertise in the management or coordination of care to

persons with chronic diseases or that has the experience of providing

cost-effective community-based care to such patients, or in the case of

a local government organization, has expressed a strong willingness to

sponsor such a program. The department may also approve disease

management demonstration programs which include, but are not limited to,

the promotion of adherence to evidence-based guidelines, improvement of

provider and patient communication and provide information on provider

and beneficiary utilization of services. The department shall grant no

fewer than six demonstration programs, no more than one-third of such

programs shall be selected to provide these services in any single

social services district; provided further, where the department grants

less than six demonstration programs, no more than one such program

shall be selected to provide these services in any single social

services district. The department shall approve disease management

demonstration programs which are geographically diverse and

representative of both urban and rural social services districts. The

program sponsor must establish, to the satisfaction of the department,

its capacity to enroll and serve sufficient numbers of enrollees to

demonstrate the cost-effectiveness of the demonstration program.

2. The department shall establish the criteria by which individuals

will be identified as eligible for enrollment in the demonstration

programs. Persons eligible for enrollment in the disease management

demonstration program shall be limited to individuals who: receive

medical assistance pursuant to title eleven of article five of the

social services law and may be eligible for benefits pursuant to title

18 of the social security act (Medicare); are not enrolled in a Medicaid

managed care plan, including individuals who are not required or not

eligible to participate in Medicaid managed care programs pursuant to

section three hundred sixty-four-j of the social services law; are

diagnosed with chronic health problems as may be specified by the entity

undertaking the demonstration program, including, but not limited to one

or more of the following: congestive heart failure, chronic obstructive

pulmonary disease, asthma, diabetes or other chronic health conditions

as may be specified by the department; or have experienced or are likely

to experience one or more hospitalizations or are otherwise expected to

incur excessive costs and high utilization of health care services.

3. Enrollment in a demonstration program shall be voluntary. A

participating individual may discontinue his or her enrollment at any

time without cause. The commissioner shall review and approve all

enrollment and marketing materials for a demonstration program.

4. The demonstration program shall offer evidence-based services and

interventions designed to ensure that the enrollees receive high

quality, preventative and cost-effective care, aimed at reducing the

necessity for hospitalization or emergency room care or at reducing

lengths of stay when hospitalization is necessary. The demonstration

program may include screening of eligible enrollees, developing an

individualized care management plan for each enrollee and implementing

that plan. Disease management demonstration programs that utilize

information technology systems that allow for continuous application of

evidence-based guidelines to medical assistance claims data and other

available data to identify specific instances in which clinical

interventions are justified and communicate indicated interventions to

physicians, health care providers and/or patients, and monitor physician

and health care provider response to such interventions, shall have the

enrollees, or groups of enrollees, approved by the department for

participation. The services provided by the demonstration program as

part of the care management plan may include, but are not limited to,

case management, social work, individualized health counselors,

multi-behavioral goals plans, claims data management, health and

self-care education, drug therapy management and oversight, personal

emergency response systems and other monitoring technologies, telehealth

services and similar services designed to improve the quality and

cost-effectiveness of health care services.

5. The department shall be responsible for monitoring the quality,

appropriateness and cost-effectiveness of a demonstration program. The

department shall utilize, to the extent possible, all potential sources

of funding for demonstration programs, including, but not limited to,

private payments and donations. All such funds shall be deposited by the

commissioner and credited to the disease management account which shall

be established by the comptroller in the special revenue-other fund.

Additionally, to the extent of funds appropriated therefor, medical

assistance funds, including any funding or shared savings as may become

available through federal waivers or otherwise under titles 18 and 19 of

the federal social security act, may be used by the department for

expenditures in support of the disease management program.

6. Payments shall be made by the department to the entity responsible

for the operation of the demonstration program on a fixed amount per

member per month of enrollment and shall reimburse the program sponsor

for the services rendered pursuant to subdivision four of this section.

The amount paid shall be an amount reasonably necessary to meet the

costs of providing such services, provided that the total amount paid

for medical assistance to enrollees in any such disease management

demonstration program, including any demonstration program expenditures,

shall not exceed ninety-five percent of the medical assistance

expenditure related to such enrollee that would reasonably have been

anticipated if the enrollee had not been enrolled in such demonstration

program. The department may make payments to demonstration programs that

provide administrative services only, provided that expenditures made

for enrollees, or a group of enrollees, participating in the

demonstration program shall provide sufficient savings as determined by

the department, had the enrollees, or groups of enrollees, not been

enrolled in such demonstration. The department shall provide an interim

report to the governor, and the legislature on or before December

thirty-first, two thousand six and a final report on or before December

thirty-first, two thousand seven on the results of demonstration

programs. Both reports shall include findings as to the demonstration

programs' contribution to improving quality of care and their

cost-effectiveness. In the final report, the department shall offer

recommendations as to whether demonstration programs should be extended,

modified, eliminated or made permanent.